Pancreatic cancer

Several factors can increase the risk of developing pancreatic cancer. These include:

• Age: Pancreatic cancer is most common in individuals aged 60 to 80.
• Smoking: Cigarette smoking is one of the leading causes of pancreatic cancer.
• Chronic pancreatitis: Long-term inflammation of the pancreas, often due to alcohol abuse or genetic conditions, increases the risk.
• Family history: A family history of pancreatic cancer or certain inherited genetic syndromes (e.g., hereditary pancreatitis, BRCA1/BRCA2 mutations, Lynch syndrome, and Peutz-Jeghers syndrome) can increase the risk.
• Diabetes: People with diabetes, particularly type 2 diabetes, are at an increased risk of developing pancreatic cancer.
• Obesity: Excess body weight is associated with an increased risk of pancreatic cancer.
• Diet: Diets high in red meat, processed foods, and low in fruits and vegetables may increase the risk.
• Chronic infection with certain viruses: Hepatitis B and certain genetic conditions like cystic fibrosis can increase the risk of developing pancreatic cancer.

Pancreatic cancer often does not cause symptoms in its early stages, which is why it is often diagnosed late. When symptoms do appear, they can include:

• Abdominal pain: Often in the upper abdomen or back, and may be worse after eating.
• Jaundice: Yellowing of the skin and eyes, often associated with dark urine, pale stools, and itchy skin. This occurs if the tumour blocks the bile duct, which is responsible for draining bile from the liver to the small intestine.
• Unexplained weight loss: This is common in many cancers, but particularly in pancreatic cancer due to loss of appetite and metabolic changes.
• Digestive problems: Nausea, vomiting, and bloating due to blockage of the digestive tract or insufficient digestive enzyme production.
• New-onset diabetes: This can occur, especially in older adults, as pancreatic cancer affects the insulin-producing cells in the pancreas.
• Fatigue: Due to the cancer and metabolic changes, individuals may experience chronic fatigue.
• Blood clots: In some cases, pancreatic cancer can lead to blood clot formation in the veins (deep vein thrombosis or DVT), which may be a sign of advanced disease.

Given that pancreatic cancer typically presents with vague symptoms, it is often diagnosed in advanced stages. However, several diagnostic methods are available:

• Imaging studies:
  • CT: A CT scan of the abdomen is commonly used to assess the pancreas and surrounding structures, detect masses, and evaluate the extent of the cancer.
  • MRI (magnetic resonance imaging): MRI can provide detailed images of the pancreas and is sometimes used to evaluate tumours or suspicious lesions.
  • Endoscopic ultrasound (EUS): This is a highly sensitive technique used to detect small tumours and obtain tissue samples (biopsy) for diagnosis. EUS is also helpful in assessing nearby blood vessels and lymph nodes.
  • PET (positron emission tomography): A PET scan can detect areas of increased metabolic activity that are often seen in cancer cells and can help determine the extent of cancer spread (staging).
• Endoscopic procedures:
  • Endoscopic retrograde cholangiopancreatography (ERCP): This procedure uses an endoscope to examine the bile and pancreatic ducts and can help detect blockages or tumours. A biopsy can be obtained during ERCP.
  • Biopsy: A tissue sample from the pancreas is often needed to confirm the diagnosis of pancreatic cancer. This may be done during an endoscopic ultrasound or ERCP.
• Blood tests:
  • CA 19-9 test: This test is used to evaluate CA 19-9, a tumour marker whose levels can be elevated in pancreatic cancer. Importantly, it is not specific to the disease and can be elevated in other conditions, such as cholestasis or pancreatitis. It is used primarily to monitor treatment response or detect recurrence after treatment.

The treatment of pancreatic cancer depends on the stage of the disease, the location of the tumour, and the patient’s overall health. The main treatment options include:

• Surgery:
  • Whipple procedure (pancreaticoduodenectomy): This is the most common surgery for locally resectable pancreatic cancer. It involves removing the head of the pancreas, the duodenum, a portion of the stomach, and sometimes the bile duct and lymph nodes.
  • Distal pancreatectomy: If the cancer is in the tail or body of the pancreas, the affected portion of the pancreas may be removed.
  • Total pancreatectomy: In some cases, the entire pancreas may need to be removed if the cancer involves a large portion of the organ.
• Chemotherapy: Common chemotherapy regimens include FOLFIRINOX (a combination of fluorouracil (5-FU), oxaliplatin, irinotecan, and leucovorin) and gemcitabine. Chemotherapy may also be used to treat advanced pancreatic cancer when surgery is not an option.
  • Adjuvant chemotherapy (chemotherapy given after surgery) is often used to kill any remaining cancer cells and reduce the risk of recurrence.
  • Neoadjuvant chemotherapy (chemotherapy given before surgery) may be used to shrink the tumour to make it more amenable to surgical resection.
• Radiation therapy: Radiation therapy can be used to shrink tumours, control pain, or help with symptoms such as obstruction of the bile duct. It may be combined with chemotherapy (chemoradiation) in some cases. It is more commonly used in locally advanced cases rather than metastatic disease.
• Targeted therapy: Targeted therapy is a newer treatment approach that uses drugs to target specific molecules involved in the growth and spread of cancer. For example, erlotinib is sometimes used for pancreatic cancer that expresses certain mutations in the EGFR (epidermal growth factor receptor).
• Immunotherapy: Immunotherapy, while still under investigation for pancreatic cancer, may hold promise for certain types of tumours with specific genetic mutations, such as those with high microsatellite instability (MSI-H) or PD-L1 expression.
• Palliative care: For advanced pancreatic cancer where curative treatment is not possible, palliative care aims to improve quality of life and relieve symptoms. This can include pain management, nutritional support, and interventions to manage obstruction of the bile duct or stomach.